Saudi Board Family Medicine Final Written Exam (SCFHS)

According to the Saudi Ministry of Health guidelines, at what age should routine breast cancer screening with screening mammography be initiated for average-risk women, and at what frequency?

• AAge 40, every 1 to 2 years
• BAge 50, every 2 years
• CAge 35, annually
• DAge 45, every 3 years

A 48-year-old asymptomatic Saudi man presents to your clinic for a routine check-up. He has no family history of colorectal cancer. Which of the following is the most appropriate recommendation for colorectal cancer screening according to local guidelines?

• AColonoscopy starting now, repeated every 10 years if normal
• BAnnual fecal immunochemical test (FIT) starting at age 50
• CFecal occult blood test (FOBT) starting at age 60
• DColonoscopy starting at age 45, repeated every 5 years

A 66-year-old male who is a former smoker (smoked 1 pack per day for 15 years, quit 10 years ago) comes for preventive care. He has no symptoms. According to screening guidelines, what screening intervention for abdominal aortic aneurysm (AAA) is indicated?

• AA one-time screening for AAA with abdominal ultrasonography
• BAnnual screening for AAA with abdominal ultrasonography
• CScreening for AAA with CT angiography of the abdomen
• DNo screening is indicated because he quit smoking more than 5 years ago

A 32-year-old married woman comes to the clinic asking about cervical cancer screening. She had a normal Pap smear 3 years ago. According to current guidelines, what is the most appropriate next step for screening?

• APerform a co-test (Pap smear and HPV testing) or high-risk HPV testing alone
• BPerform a Pap smear now, and repeat every year
• CReassure her and schedule a repeat screening at age 40
• DNo screening is required as she is under 35 and has no symptoms

A 55-year-old heavy smoker (35 pack-year history) who currently smokes asks about lung cancer screening. He has no cough, hemoptysis, or weight loss. What is the standard screening recommendation for this patient?

• AAnnual screening with low-dose computed tomography (LDCT)
• BScreening with chest X-ray and sputum cytology every 2 years
• COne-time screening with high-resolution CT (HRCT)
• DNo screening is indicated unless he develops symptoms

A 65-year-old postmenopausal woman visits your clinic for a routine checkup. She has no history of fractures and no secondary causes of bone loss. Her BMI is 24. What is the most appropriate osteoporosis screening recommendation?

• ADual-energy X-ray absorptiometry (DEXA) of the hip and lumbar spine
• BQuantitative ultrasound of the calcaneus
• CSerum calcium, phosphorus, and alkaline phosphatase levels
• DNo screening is required unless she has lost height

A 23-year-old male medical student is preparing to begin his clinical rotations at a major hospital in Riyadh. He had a documented positive tuberculin skin test (TST) (15 mm induration) two years ago, for which he did not receive treatment. He is currently asymptomatic. What is the most appropriate next step in management?

• AObtain a chest radiograph to rule out active tuberculosis
• BRepeat the TST to confirm the results
• CPerform an Interferon-Gamma Release Assay (IGRA)
• DInitiate immediate treatment with isoniazid for 9 months without further tests

A 35-year-old obese Saudi female (BMI 34 kg/m²) presents with fatigue. She has a strong family history of type 2 diabetes. What is the recommended screening strategy for type 2 diabetes in this patient?

• AScreen now with HbA1c or fasting plasma glucose, and repeat every 3 years if normal
• BScreen now with a 2-hour oral glucose tolerance test, and repeat annually
• CScreen starting at age 45; no screening is needed now because she is under 40
• DScreen only if she develops classic symptoms of polyuria and polydipsia

A 62-year-old healthy female plans to perform the Hajj pilgrimage this year. She has no chronic diseases and last received her vaccines during childhood. In addition to the mandatory meningococcal vaccine, which vaccine should be strongly recommended to her before travel?

• AInfluenza vaccine
• BYellow fever vaccine
• CRabies vaccine
• DHepatitis A vaccine

A 40-year-old female presents to your clinic for a routine check-up. She has a history of gestational diabetes 5 years ago, but her postpartum glucose tolerance test was normal. She has no current symptoms of diabetes. What is the most appropriate screening recommendation for diabetes for this patient?

• AScreen now with fasting plasma glucose or HbA1c, and repeat every 3 years
• BNo screening is needed until she reaches age 45
• CScreen only if her body mass index (BMI) rises above 30 kg/m²
• DScreen with an oral glucose tolerance test every 5 years

A 65-year-old male with chronic obstructive pulmonary disease (COPD) presents for his annual influenza vaccine. He has never received any pneumococcal vaccine. What is the most appropriate pneumococcal vaccination schedule for this patient?

• AAdminister PCV20 (Pneumococcal Conjugate Vaccine) now
• BAdminister PPSV23 (Pneumococcal Polysaccharide Vaccine) now, followed by PCV15 in 1 year
• CAdminister PCV13 now, and no further doses are required
• DAdminister PPSV23 now, and repeat it every 5 years

A 28-year-old pregnant woman in her 28th week of gestation presents to the antenatal clinic. She received a Tdap (Tetanus, Diphtheria, Pertussis) vaccine during her previous pregnancy 2 years ago. What is the most appropriate recommendation regarding Tdap vaccination during her current pregnancy?

• AAdminister Tdap vaccine now (between 27 and 36 weeks of gestation)
• BDo not administer Tdap, as she received it less than 5 years ago
• CAdminister Tdap only after delivery (postpartum)
• DAdminister a tetanus toxoid (TT) vaccine instead of Tdap

A 34-year-old healthy male requests screening for prostate cancer. He has no urinary symptoms and no family history of prostate cancer. What is the most appropriate counseling/action regarding prostate cancer screening in this patient?

• AAdvise against screening at this age, as screening is not recommended for men under 50 wi…
• BOrder a serum Prostate-Specific Antigen (PSA) test and perform a digital rectal examinati…
• CScreen with serum PSA now and repeat every 2 years
• DPerform a digital rectal exam (DRE) only, as PSA has a high rate of false positives

A 50-year-old asymptomatic Saudi woman comes for a health maintenance visit. She has no risk factors for cardiovascular disease. Her clinic blood pressure is 124/82 mmHg. What is the most appropriate screening and follow-up strategy for hypertension in this patient?

• AConfirm normal blood pressure and rescreen in 1 year
• BDiagnose stage 1 hypertension and start medication
• CPerform ambulatory blood pressure monitoring immediately
• DRescreen in 3 to 5 years since her blood pressure is normal (<130/80 mmHg) and she has no…

A 29-year-old female presents to your clinic for a pre-employment physical. She is asymptomatic. She mentions that she received the HPV (Human Papillomavirus) vaccine series at age 12. How does her vaccination history affect her cervical cancer screening schedule?

• AShe should follow the standard cervical cancer screening guidelines regardless of her HPV…
• BShe does not require cervical cancer screening since she was vaccinated before sexual deb…
• CShe should start screening at age 35 instead of age 21 to 25
• DShe only needs screening every 10 years instead of every 3 to 5 years

A 42-year-old male with a history of obesity (BMI 31) presents to your clinic. He does not smoke and has no personal or family history of premature cardiovascular disease. His fasting lipid profile shows Total Cholesterol: 5.4 mmol/L, LDL: 3.5 mmol/L, HDL: 1.0 mmol/L, and Triglycerides: 2.1 mmol/L. What is the most appropriate next step in cardiovascular risk prevention?

• ACalculate his 10-year Atherosclerotic Cardiovascular Disease (ASCVD) risk score
• BInitiate therapy with low-dose atorvastatin (10 mg daily)
• CRepeat the lipid panel in 3 months after a strict fat-free diet
• DReassure him that his lipids are acceptable and review in 5 years

Which of the following is correct regarding Vitamin D screening in healthy, asymptomatic adults according to the majority of clinical guidelines?

• ARoutine screening of Vitamin D levels in asymptomatic, average-risk adults is not recomme…
• BAll adults living in the Arabian Peninsula should be screened annually for Vitamin D defi…
• CScreening should be performed only in postmenopausal women with a BMI < 20
• DFasting serum 25-hydroxyvitamin D is the preferred screening test for all adults starting…

A 19-year-old female presents to your clinic for a routine checkup. She is healthy, takes no medications, and is sexually active. Which screening test is recommended for her at this visit?

• AScreening for Chlamydia trachomatis infection
• BScreening for cervical cancer with a Pap smear
• CScreening for type 2 diabetes with a fasting glucose
• DScreening for lipid disorders with a lipid panel

A 52-year-old healthy male who has never smoked asks if he should start taking aspirin 81 mg daily for the primary prevention of myocardial infarction. He has no history of cardiovascular disease or bleeding. What is the most appropriate advice?

• AAdvise against initiating low-dose aspirin for primary prevention, as the risk of GI blee…
• BRecommend starting aspirin 81 mg daily to reduce the risk of ischemic stroke
• CAdvise him to take aspirin only on days when he eats high-fat meals
• DSuggest taking aspirin combined with a proton pump inhibitor to eliminate all risks

A 45-year-old female presents to your clinic complaining of generalized body aches and fatigue. In your preventive health checklist, which screening tool is recommended to identify intimate partner violence (IPV) in women of reproductive age?

• AHITS (Hurt, Insult, Threaten, Scream) screening tool
• BCAGE questionnaire
• CPHQ-9 questionnaire
• DGAD-7 questionnaire

A 52-year-old Saudi male with a history of type 2 diabetes presents for hypertension management. His average home blood pressure readings are 146/92 mmHg despite lifestyle changes. Which of the following is the most appropriate first-line antihypertensive agent?

• ALisinopril
• BAmlodipine
• CHydrochlorothiazide
• DMetoprolol succinate

A 58-year-old female with type 2 diabetes and established heart failure with reduced ejection fraction (HFrEF) has an HbA1c of 8.2% on metformin 1000 mg twice daily. What is the most appropriate next step in her pharmacological management according to current guidelines?

• AAdd Empagliflozin
• BAdd Gliclazide
• CAdd Pioglitazone
• DAdd Sitagliptin

A 28-year-old male with mild persistent asthma presents to your clinic. He complains of chest tightness and wheezing 3-4 times a week, requiring his albuterol inhaler. He has no nighttime awakenings. According to the current Global Initiative for Asthma (GINA) guidelines, what is the preferred controller therapy?

• ALow-dose inhaled corticosteroid (ICS) - formoterol taken as needed for symptoms
• BLow-dose ICS taken daily with albuterol as needed
• CDaily long-acting beta-agonist (LABA) monotherapy
• DDaily oral montelukast monotherapy

A 64-year-old male with a history of severe COPD presents with progressive dyspnea. He has had 2 moderate exacerbations in the past year requiring oral steroids. His current regimen is salmeterol (LABA) twice daily. Spirometry shows FEV1 48% predicted. According to the GOLD 2023/2024 guidelines, what is the most appropriate modification to his therapy?

• AChange to a combination of a Long-Acting Muscarinic Antagonist (LAMA) and LABA
• BAdd daily oral prednisone 5 mg
• CAdd daily theophylline
• DChange to a combination of LABA and Inhaled Corticosteroid (ICS)

A 60-year-old male with chronic kidney disease (CKD) stage 3a (eGFR 50 mL/min/1.73 m²) and a urine albumin-to-creatinine ratio (UACR) of 450 mg/g presents for follow-up. His blood pressure is 138/85 mmHg on no medications. Which of the following is the best initial drug to manage his blood pressure and slow CKD progression?

• ARamipril
• BAmlodipine
• CMetolazone
• DSpironolactone

A 28-year-old pregnant woman in her first trimester, who has a history of primary hypothyroidism, presents to your clinic. Her current dose of levothyroxine is 100 mcg daily, and her pre-pregnancy TSH was 1.8 mIU/L. What is the most appropriate next step regarding her levothyroxine dosage?

• AIncrease the dose of levothyroxine by approximately 30%
• BMaintain her current levothyroxine dose and recheck TSH in 4 weeks
• CDecrease the dose of levothyroxine because maternal thyroid demand decreases in early pre…
• DSwitch her to liothyronine (T3) monotherapy

A 32-year-old female presents with palpitations, weight loss, and heat intolerance. Laboratory tests confirm hyperthyroidism (TSH < 0.01 mIU/L, Free T4 elevated) and positive thyroid-stimulating immunoglobulin (TSI), establishing a diagnosis of Graves' disease. She expresses a desire to become pregnant in the near future. Which of the following is the most appropriate first-line antithyroid medication for this patient?

• APropylthiouracil (PTU)
• BMethimazole
• CRadioactive iodine ablation
• DPropranolol monotherapy

A 45-year-old male with a history of acute coronary syndrome (ACS) 6 months ago is currently taking atorvastatin 80 mg daily. His repeat lipid panel shows an LDL cholesterol level of 2.1 mmol/L (81 mg/dL). According to current guidelines for secondary prevention, what is the most appropriate next step in management?

• AAdd Ezetimibe 10 mg daily
• BIncrease Atorvastatin to 120 mg daily
• CAdd a PCSK9 inhibitor
• DContinue current therapy; his LDL is at target

A 54-year-old male with a history of recurrent gouty arthritis presents for a follow-up. He has had 3 painful flares in the last 12 months. His serum uric acid level is 520 umol/L (8.7 mg/dL). He has normal renal function. What is the most appropriate long-term management strategy?

• AInitiate Allopurinol 100 mg daily and co-prescribe low-dose colchicine for prophylaxis
• BInitiate Allopurinol 300 mg daily only during acute flares
• CPrescribe Indomethacin to be taken daily as maintenance therapy
• DInitiate Febuxostat 80 mg daily as the first-line drug of choice

A 66-year-old female with heart failure with reduced ejection fraction (HFrEF, EF 32%) is currently stable on Enalapril 10 mg twice daily, Carvedilol 25 mg twice daily, and Spironolactone 25 mg daily. Despite this, she has persistent mild dyspnea on exertion (NYHA Class II). What adjustment to her medication regimen is most appropriate to reduce mortality and hospitalization?

• ASwitch Enalapril to Sacubitril/Valsartan
• BAdd Digoxin 0.125 mg daily
• CAdd Amlodipine 5 mg daily
• DIncrease Spironolactone to 50 mg daily

A 62-year-old male with a history of stable angina presents for a routine visit. He has been asymptomatic on Aspirin 100 mg daily, Bisoprolol 5 mg daily, and Simvastatin 40 mg daily. His heart rate is 58 bpm and blood pressure is 118/74 mmHg. What is the most appropriate long-term antianginal strategy for this patient?

• AContinue current medical therapy, as he is stable and asymptomatic
• BAdd Isosorbide mononitrate to improve exercise tolerance
• CRefer him for elective coronary artery bypass grafting (CABG)
• DAdd Clopidogrel 75 mg daily for dual antiplatelet therapy

A 72-year-old female presents with fatigue. An ECG reveals atrial fibrillation with a ventricular rate of 88 bpm. She has a history of hypertension and type 2 diabetes. She has no valvular heart disease. Her CHA2DS2-VASc score is calculated. What is the most appropriate management regarding anticoagulation?

• AInitiate a Direct Oral Anticoagulant (DOAC) such as Apixaban
• BInitiate Aspirin 100 mg daily
• CInitiate Warfarin with a target INR of 2.0 to 3.0
• DNo anticoagulation is required as her ventricular rate is well controlled

A 68-year-old female presents with bilateral knee pain that worsens with walking and is relieved by rest. She has morning stiffness lasting 15 minutes. Physical exam reveals bony enlargement (Heberden's and Bouchard's nodes) and crepitus. She has a history of peptic ulcer disease. Which of the following is the most appropriate first-line pharmacological treatment?

• ATopical NSAIDs (e.g., Diclofenac gel)
• BOral Naproxen 500 mg twice daily
• COral Acetaminophen (Paracetamol) 1g four times daily
• DIntra-articular methylprednisolone injection

A 34-year-old female presents with a 3-month history of symmetrical joint pain and swelling in her hands and wrists. Laboratory tests show positive Rheumatoid Factor (RF) and high titers of anti-cyclic citrullinated peptide (anti-CCP) antibodies. Plain radiographs of the hands show early joint space narrowing. What is the most appropriate next step in management?

• AInitiate Methotrexate and refer to rheumatology
• BPrescribe oral Prednisolone 15 mg daily as monotherapy
• CStart Celecoxib and review in 6 months
• DCheck serum uric acid and recommend a low-purine diet

A 48-year-old male complains of frequent heartburn and acid regurgitation, especially after meals and when lying down. He has no dysphagia, weight loss, or family history of upper GI malignancy. He is started on omeprazole 20 mg daily. After 8 weeks of therapy, he reports complete resolution of symptoms. What is the most appropriate next step in his management?

• AAttempt to taper and discontinue the proton pump inhibitor (PPI) or transition to as-need…
• BContinue Omeprazole 20 mg daily indefinitely
• CRefer for an upper gastrointestinal endoscopy (EGD)
• DPerform a urea breath test for Helicobacter pylori

A 28-year-old female presents with chronic abdominal pain and bloating that is relieved by defecation. She reports that her bowel movements alternate between loose, watery stools and hard, lumpy stools. Her symptoms have been present for the past 6 months. She has no weight loss, nocturnal diarrhea, or rectal bleeding. What is the most appropriate diagnostic approach?

• ADiagnose Irritable Bowel Syndrome (IBS) using the Rome IV clinical criteria
• BRefer for a colonoscopy to rule out inflammatory bowel disease
• COrder a CT scan of the abdomen and pelvis with contrast
• DObtain multiple stool cultures and examine for ova and parasites

A 35-year-old female presents with recurrent throbbing headaches, unilateral, lasting 24-48 hours, accompanied by nausea and photophobia. She has about 6 headache days per month, which cause significant impairment in her work. She currently uses ibuprofen and sumatriptan for acute attacks. What is the most appropriate next step in her management?

• AInitiate migraine preventive therapy (e.g., Propranolol or Amitriptyline)
• BIncrease the dose of oral Sumatriptan
• COrder an urgent MRI of the brain
• DAdvise daily use of Ibuprofen for prophylaxis

A 68-year-old male complains of progressive nocturia, weak urinary stream, and hesitancy. Digital rectal examination reveals a smooth, symmetrically enlarged prostate (estimated volume 45 mL). Urinalysis is normal. His PSA is 1.8 ng/mL. He has no history of urinary retention. What is the most appropriate initial medical therapy?

• AAn alpha-1 blocker (e.g., Tamsulosin)
• BA 5-alpha-reductase inhibitor (e.g., Finasteride) as monotherapy
• CA loop diuretic (e.g., Furosemide) taken at bedtime
• DRefer for immediate transurethral resection of the prostate (TURP)

A 70-year-old female presents with bilateral leg swelling, skin hyperpigmentation, and stasis dermatitis around the ankles. She has a history of deep vein thrombosis 5 years ago. Duplex ultrasound confirms deep venous reflux. What is the primary non-pharmacological treatment for this chronic condition?

• AGraduated compression stockings
• BStrict bed rest with leg elevation
• CLong-term oral anticoagulation
• DSurgical vein stripping

A 45-year-old female presents with a 1-year history of widespread musculoskeletal pain, chronic fatigue, poor sleep, and cognitive difficulties ('brain fog'). Physical exam reveals multiple tender points but no joint swelling or muscle weakness. Extensive laboratory testing (including CBC, ESR, CRP, TSH, and ANA) is entirely normal. What is the most appropriate first-line pharmacological agent for this patient's condition?

• AAmitriptyline or Pregabalin
• BOral Prednisolone 10 mg daily
• COxycodone controlled-release
• DLong-term daily Celecoxib

A 45-year-old previously healthy female presents with a 3-day history of cough, productive of rust-colored sputum, fever, and right-sided pleuritic chest pain. Her vitals are: Temp 38.5 C, HR 92 bpm, RR 18 breaths/min, BP 115/75 mmHg, and Oxygen saturation 96% on room air. She is alert and oriented. Chest X-ray confirms right lower lobe consolidation. What is the most appropriate management according to the CURB-65 score and standard guidelines?

• AOutpatient treatment with oral Amoxicillin or Doxycycline
• BInpatient treatment with intravenous Ceftriaxone and Azithromycin
• COutpatient treatment with oral Ciprofloxacin
• DInpatient admission to the Intensive Care Unit (ICU) for broad-spectrum antibiotics

A 32-year-old male presents with nasal congestion, facial pain, and purulent nasal discharge for 5 days. He has a low-grade fever but no severe headache or visual symptoms. He has not taken any medications. What is the most appropriate initial management?

• ASymptomatic therapy (nasal saline spray, oral decongestants, and analgesics)
• BInitiate Amoxicillin-Clavulanate for 7 days
• COrder a CT scan of the paranasal sinuses
• DPrescribe oral Prednisolone 40 mg daily for 5 days

A 12-year-old boy presents with a sore throat, fever of 38.8 C, and painful swallowing for 2 days. On exam, he has tonsillar exudates, tender anterior cervical lymphadenopathy, and no cough. What is the most appropriate next step in management?

• APerform a Rapid Antigen Detection Test (RADT) or throat culture
• BPrescribe Amoxicillin immediately based on clinical findings
• CPrescribe Azithromycin immediately
• DReassure the parent that it is viral and recommend supportive care only

A 3-year-old child is brought to the clinic by his mother due to right ear pain and fever of 38.2 C for 24 hours. Otoscopic examination reveals a bulging, opaque, erythematous tympanic membrane with poor mobility. The child is alert and drinking fluids well. What is the most appropriate management?

• APrescribe high-dose Amoxicillin (80-90 mg/kg/day)
• BProvide ear drops containing ciprofloxacin and dexamethasone
• CReassure the mother and recommend observation for 48-72 hours with ibuprofen
• DPerform an immediate tympanocentesis

A 24-year-old sexually active female presents with a 2-day history of dysuria, urinary frequency, and urgency. She has no fever, flank pain, or vaginal discharge. She is not pregnant. What is the most appropriate empiric treatment for this patient?

• ANitrofurantoin monohydrate/macrocrystals 100 mg twice daily for 5 days
• BAmoxicillin 500 mg three times daily for 7 days
• CCiprofloxacin 500 mg twice daily for 3 days
• DAzithromycin 1 g single oral dose

A 26-year-old female presents with fever of 38.9 C, chills, nausea, and severe right-sided flank pain for 24 hours. On exam, she has marked right costovertebral angle (CVA) tenderness. Urinalysis shows pyuria and bacteriuria. She is alert, has no vomiting, and has a blood pressure of 115/70 mmHg. What is the most appropriate management?

• AOutpatient treatment with oral Ciprofloxacin 500 mg twice daily for 7 days
• BInpatient admission for intravenous Ceftriaxone
• COutpatient treatment with oral Nitrofurantoin for 10 days
• DOutpatient treatment with oral Amoxicillin for 14 days

A 2-year-old child is brought to the emergency department due to watery diarrhea and 3 episodes of vomiting over the past 24 hours. On examination, the child is irritable, has slightly dry mucous membranes, tears are present when crying, and has a normal capillary refill time (< 2 seconds). He is thirsty and drinks water eagerly. What is the most appropriate initial management?

• AOral rehydration therapy (ORT) using low-osmolarity oral rehydration salts (ORS)
• BIntravenous fluid bolus with 20 mL/kg of 0.9% normal saline
• CAdminister oral loperamide to stop the diarrhea
• DPrescribe empiric oral metronidazole